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Delta Dental of Virginia Clinical Policy # 705
Subject
Originating Department
Clinical Professional Services
Prophylactic Removal of Third Molar Teeth
Signature Authority
Dental Director
Type:
New
Date:
11.15.2011
Preamble:
Replacement
Revision
Clarification
Revision Date:
The Clinical Policy Bulletin is an expression of Delta Dental of Virginia’s (DDVA)
determination regarding whether certain services or supplies are medically or
dentally necessary. DDVA bases its conclusions on a review of currently available
clinical literature. This includes, but is not limited to, clinical outcome studies
published in the peer-reviewed medical and dental literature, regulatory status of
the technology, evidence-based guidelines of public health and health research
agencies, evidence-based guidelines and positions of leading national health
professional organizations, views of physicians and dentists practicing in pertinent
clinical areas, and other applicable information. DDVA reserves the right to revise
these policies as new clinical information is available and we welcome submission
of further relevant information.
A group may define covered dental services under their dental plan, as well as
those services that may be subject to dollar caps or other limits. The plan
documents outline covered benefits, exclusions and limitations. DDVA advises
dentists and subscribers to consult the plan documents to determine if there are
exclusions or other benefit limitations applicable to the service request. The
conclusion that a particular service is medically or dentally necessary does not
constitute an indication or warranty that the service requested is a covered benefit
payable by DDVA. Some plans exclude coverage for services that DDVA
considers either medically or dentally necessary. When there is a discrepancy
between DDVA’s clinical policy and the group’s plan documents, DDVA is to defer
to the group’s plan documents as to whether the dental service is a covered
benefit. In addition, if state or federal regulations mandate coverage then DDVA
will adhere to the applicable regulatory requirement.
History:
Removal of third molar teeth at an early stage of development is a common
recommendation by orthodontists for adolescents undergoing orthodontic
treatment. While some may be indicated in young adolescents, providers should
be aware that the prophylactic removal of third molars may be a non-covered
benefit, as these extractions do not meet the definition of dental necessity or the
specific parameter of certain dental plans, which benefit the removal of
symptomatic or diseased teeth only.
Systematic reviews of the literature do not support prophylactic removal of
unerupted third molar teeth that are not associated with a specific pathologic
process warranting removal(1,2,3,4,5).
For benefits to be considered, third molar removals must meet the criteria for the
treatment of impacted teeth as defined by the ADA CDT manual(6). The ADA CDT
manual defines an impaction as: “An unerupted or partially erupted tooth that is
positioned against another tooth, bone, or soft tissue so that complete eruption is
unlikely.” To qualify for removal as an impaction, a tooth must exhibit an
impediment to a normal eruptive pattern such as horizontal orientation, significant
mesial or distal angular inclination, or some other abnormal anatomic position,
such as a partially erupted tooth with little space to accommodate adequate
occlusion. Of note is the fact that the position of unerupted third molar teeth can
change through the middle of the third decade(7). Documentation of the need for
removal is required. Therefore, providers must submit diagnostic X-rays and a
narrative/treatment rationale documenting the dental or medical necessity for
removal.
Otherwise, if the teeth do not meet the definition of a true impaction and are
unerupted, the teeth must be associated with the presence of some localized
pathologic process, such as infection/pericoronitis resulting from food impaction
causing multiple episodes of purulent exudate, inflammation; adjacent tooth
resorption; bone loss of the adjacent tooth; pathologic cyst formation; traumatic
occlusion from an opposing tooth; or pain associated with a localized, identifiable
causative factor.
Removal of teeth for relief of non-specific symptoms, such as “headaches,” “jaw
pain,” and discomfort associated with temporomandibular joint dysfunction
(TMJ/TMD), do not meet criteria for treatment.
Additionally, removal of third molar teeth to “prevent crowding” or post-orthodontic
“relapse” does not meet the criteria for treatment. The role of third molar teeth
relative to crowding may or may not be significant(2,3,8,9) and research has
shown the etiology of tooth crowding to be nonspecific and multifactorial(10,11).
The removal of third molar teeth has been shown to have no effect on late lower
incisor crowding(12). No available research specifically isolates the presence of
third molar teeth as a causative factor in crowding(13). The American Association
of Oral and Maxillofacial Surgeons has issued the following statements: “Despite
good intentions, we are not able to explain, predict, or prevent crowding, no matter
what the cause. While it is likely that third molars play at least some role in the
etiology of crowding, they are only one factor to consider in making a clinical
decision about third molar management”(14).
Arch length discrepancies are often cited by practitioners as an indication for
removal of unerupted third molar teeth. However, the age of the patient relative to
continued growth of the maxilla and mandible must be taken into consideration.
Research shows significant growth between the ages of eleven and
seventeen(15), with mandibular growth approximately twice that of the maxilla(16).
Facial growth is approximately 98% completed by age 17-18 in adolescent males
and by age 15 in adolescent females(17). Facial growth may continue past these
ages, and in particular, late mandibular growth is often observed in post-pubertal
teens(18).
Policy:
Codes(19):
References:
DDVA recommends that, prior to removal of bone/soft tissue impacted, unerupted
teeth not associated with a localized pathologic process, providers submit a
predetermination of benefits. Providers may refer to treatment guidelines on tooth
extraction at www.deltadentalva.com; see Clinical Policy #700.
D7220, D7230, D7240, D7241
1. Song F, Landes DP, et al. Prophylactic removal of impacted third molars: an
assessment of published reviews. Br Dent J 1997;182:339-346.
2. Song F, O’Meara S, et al. The effectiveness and cost-effectiveness of
prophylactic removal of wisdom teeth. Health Tech Assess 2000;4:1-55.
3. Mettes TG, Nienhuijs ME, et al. Interventions for treating asymptomatic
wisdom teeth in adolescents and adults. Cochrane Database Syst Rev 2005,
Issue 2. Art No: CD003879.
4. Adeyemo WL. Do pathologies associated with impacted third molars justify
prophylactic removal? A critical review of the literature. OSOMOPORE
2006;102:448-52.
5. Friedman JW. The prophylactic extraction of third molars: A public health
hazard. Amer J Pub Health 2007;97:1554-1559.
6. American Dental Association. Current Dental Terminology. CDT 20112012;216. (©ADA 2010).
7. Venta I. Radiographic follow-up of impacted third molars from age 12 to 32
years. Int J Oral Maxillofac Surg 2001(-04?);30:54-57.
8. Kahl-Nieke B, Fischbach H and Schwarze CW. Post-retention crowding and
incisor irregularity; a long term follow-up evaluation of stability and relapse. Br
J Othhodont 1995; 22:249-257.
9. Southard TE. Third molars and incisor crowding: when removal is
unwarranted. J Amer Dent Assoc 1992;123:75-769.
10. Hicks EP. Third molar management: a case against routine removal in
adolescent and young adult orthodontic patients. J Oral Maxillofac Surg
1999; 57:831-836.
11. Zachrisson BU. Mandibular third molars and late lower arch crowding - the
evidence base. World J Othodont 2005;180:180-186.
12. Harradine NW, Pearson MH and Toth B. The effect of extraction of third
molars on late lower incisor crowding: a randomized controlled trial. Br J
Orthodont 1998;25:117-122.
13. Sampson WJ. Current controversies in late incisor crowding. Ann Acad Med
Sing 1995;24:129.
14. Amer Association of Oral and Maxillofacial Surgeons. AAOMS Surgical
Update. 2007;21(1):8.
15. Smartt JM, Low DW and Bartlett SP. Plastic and Reconstructive Surgery.
July 2005. Dept of Surg. Div of Plastic Surg. Univ Penn Medical Ctr
Children’s Hosp. Phila PA.
16. Banafsheh KO and Nanda RS. Comparison of maxillary and Mandibular
growth. Amer J of Orthodon Dentofac Orthoped 2004;125:148-159.
17. Wolford LM, Spiro CK and Mehra P. Considerations for orthognathic surgery
during growth, Part 1: Mandibular deformities. Amer J Orthodon Dentofac
Orthoped 2001;119:95-101.
18. Head PN, Leite L and Zhou J. Mandible growth in late teen caucasian males.
Dept Ped Dentistry and Orthodon. Med Univ So Car. Charleston So Car.
2010.
19. American Dental Association. Current Dental Terminology. CDT 20112012:57-58. (©ADA 2010).